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HOMEOWNERS ENROLLMENT FORM
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How do I enroll electronically?

Step 1 - Complete the enrollment form below. Be sure to select the plan you want.

Step 2 - Please double-check your information before submitting your enrollment.

Step 3 - Submit the form when finished.

Physical Address of Protected Appliances
  Name:  
  Address:  
  City:  
  State:   Zip:  
  Phone:  
  Email:  
Mailing Address and Phone if different (optional)
  Mailing address:
  
  Mailing city:  
  Mailing state:   Zip:  
  Mailing phone:  

Please enroll me in the package selected below.

Homeowners
  Select package

 Full-house - $46/month. Protects the washer, dryer, range, dishwasher, refrigerator, heating and cooling system, and water heater.  
  Kitchen/Laundry - $20/month. Protects the washer, dryer, range, dishwasher and refrigerator.  
Heating/Cooling - $28/month. Protects the heating and cooling system and water heater.
       
  If you have additional appliances or more than one appliance (for example, a second refrigerator) that you want to protect, please indicate below what additional and second appliances you want to protect.  
 
Attic Fan - $4/month Refrigerator - $6/month
Furnace/AC - $25/month Microwave - $4/month
Freezer - $6/month A/C - $18/month
Trash Compactor - $4/month Water Heater - $4/month
Furnace - $14/month  
 

  We are always looking to expand our product offering and learn more about our customers. Please complete the survey below so we may better serve you in the future. This information will not be sold or given to a third party.  

Optional Information
  I live in one of the following:




 House
Apartment
Mobile Home
Other, which is a 		 
       
  This is my new home,
and I am closing on:		  
       
  My residence: Own   Rent  
       
  I was born in the year:  
       
  I heard about this
program through a:
Friend, name:
Servicer, name:
Realtor, name:
Utility, name:
Direct Mail Piece
Radio
Billboard
Magazine
Newspaper
Television
Internet
Other, specify:
 

Payment Options
  Please automatically charge my account each month for my payment.  
    Please charge my account on the day of the month.  
    CAP will contact you for the bank routing number and your account number. Would you prefer CAP to contact you by for this information.  
       
  Please charge my each month for my payment. CAP will contact you for your credit card information. Would you prefer CAP to contact you by for this information.  
       
  Please send me a bill each month. An additional $2/month fee will be added to my bill for this option. CAP will send you a bill after receiving your enrollment.  
       
  Please bill me annually. CAP will send you a bill for 12 months service after receiving your enrollment.  

Any questions or problems, please call toll free 800-978-2022.